Acta Orthop. Belg., 2007, 73, 451-457 ORIGINAL STUDY

Correction of chronic lunotriquetral instability using extensor retinacular split : A retrospective study of 26 patients

Ilkka ANTTI-POIKA, Jukka HYRKÄS, Liisa M VIRKKI, Daisuke OGINO, Yrjö T KONTTINEN

From the Orto-Lääkärit Medical Center, Helsinki, Finland, Helsinki University Central Hospital, Helsinki, Finland, the ORTON Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland, and the COXA Hospital for the Joint Replacement, Tampere, Finland

Arthroscopy offers a welcome and reliable supple- INTRODUCTION ment to the current tool set for the diagnosis of lunotriquetral (LT) instability. This study reports the Lunotriquetral (LT) instability may occur as an findings of LT-lesions during arthroscopy and the isolated ligamentous injury of the LT-joint (7) or, clinical results obtained after using dorsal stabilisa- probably in most cases, together with some other tion in its surgical management using extensor reti- injuries of the ulnar side of the wrist. It causes rest nacular split. LT-instability of grade I-III was diag- pain and mostly activity-induced pain in grip nosed in 26 patients. Imaging results were normal, activities, and leads to giving away sensations. The Reagan’s ballottement and Watson tests were posi- diagnosis of lunotriquetral instability is based part- tive in 47% and 79%, respectively. After arthroscop- ly on the patient history and the injury mechanism, ic diagnosis, the procedure was immediately contin- ued with an open repair utilising an 8-10 mm wide and radial-based extensor retinacular split for dorsal capsular reinforcement. At 39 months (range : 14 to ■ Ilkka Antti-Poika, MD, PhD, Senior Hand Surgeon. 84) follow-up, 64% had no or only occasional mild ■ Jukka Hyrkäs, MD, Senior Hand Surgeon. pain and 36% had pain with overuse or lifting. Orto-Lääkärit Medical Center, Helsinki, Finland. Overall scoring encompassing pain, patient satisfac- ■ Daisuke Ogino, PhD, Post doctoral Fellow. tion, range of motion and grip strength, was excellent Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland. in 24% and good in 64%. Only three patients had ■ Liisa M Virkki, MSc, PhD Student. fair results, one after a further injury leading to dis- Department of Medicine, Helsinki University Central tal radio-ulnar joint (DRUJ) instability, and two with Hospital, Helsinki, Finland and ORTON Orthopaedic Hospital concurrent DRUJ-stabilisation. One further patient of the Invalid Foundation, Helsinki, Finland. required a secondary procedure. Arthroscopy seems ■ Yrjö T Konttinen, MD, PhD, Professor. to allow accurate diagnosis of LT-instability and can Department of Medicine, Helsinki University Central be continued in the same session using a straight- Hospital, Helsinki, Finland, ORTON Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland and COXA Hospital forward reconstruction procedure providing satis- for the Joint Replacement, Tampere, Finland. factory results. Correspondence : Ilkka Antti-Poika, Orto-Lääkärit Medical Keywords : wrist ; lunotriquetral instability ; extensor Center, Yrjönkatu 36 A, 00100 Helsinki, Finland. E-mail : [email protected]. retinacular split. © 2007, Acta Orthopædica Belgica.

No benefits or funds were received in support of this study Acta Orthopædica Belgica, Vol. 73 - 4 - 2007 452 I. ANTTI-POIKA, J. HYRKÄS, L. M. VIRKKI, D. OGINO, Y. T. KONTTINEN which are often difficult to recall, and proper diag- lunotriquetral instability, two were lost to follow-up, and nosis and treatment are therefore delayed (9). the outcomes were evaluated for 26 patients. During the past 20 years, the cornerstones of the The mean age of the patients at the time of the oper- correct diagnosis of LT instability have been pain ation was 35 years (range : 14 to 54). Sixty two percent and tenderness over the LT-joint and a positive (n = 16) of the patients were women. The occupations of the patients were as follows : lunotriquetral ballottement test (7). Radiographs may show slight narrowing and cystic changes on Office, sales, management 10 (38%) both sides of the LT-joint, computerised tomogra- Student 5 (19%) phy can further depict the bony structures of the Healthcare, childcare, education 4 (15%) LT-joint, but more recently MRI and especially Industrial 2 (8%) arthroscopy of the radiocarpal and midcarpal joint Transportation 2 (8%) Agricultural 1 (4%) have revolutionised the diagnostics (2). Sports, physical education 1 (4%) Magnetic resonance imaging provides informa- Unknown 1 (4%) tion on the status of the extrinsic and intrinsic ligaments and joint capsule, but it does not allow The injury mechanisms were a fall on the hand in testing of the instability of the LT-joint. Therefore, 10 patients (38%), trauma without falling in 11 patients (42%), no acute trauma in 3 patients (12%) and a seque- arthroscopy offers a welcome and most reliable lae of radial fracture in 2 patients (8%). Of those who supplement to the current diagnostic tool set. fell, six did so when walking or performing some other During normal arthroscopic examination the LT- daily activity, such as walking in stairs, and three when joint is viewed on both radiocarpal and midcarpal performing sports or some equivalent physical activity sides, which allows exact visualisation of the (cycling, rollerblading and football). One further patient location and type of the damage. After arthroscopy fell two meters from a ladder. Of the traumas not involv- has confirmed the diagnosis of lunotriquetral ing a fall, five were related with sports (volleyball, ice instability, specific site-directed treatment can be hockey, floor hockey, tennis and acrobatics), three provided during the same anaesthesia by convert- involved other activities (usage of tools in two and lift- ing the diagnostic arthroscopy to an operative ing injury in one) and three were twisting injuries with- procedure. This is very relevant as the diagnosis by out detailed history. The traumas by falling or without itself is not the goal but is only a means for plan- falling involved twisting, hyperextension or supination injuries of the wrists. In addition, two traumas with a fall ning an injury-type specific treatment. We used this involved a radius fracture. option and developed a new operative modification The right wrist was injured in 14 of the patients for stabilisation of lunotriquetral instability. This is (54%) and the left in 12 (46%). Twelve patients injured particularly important because many of these their dominant hand, and twelve injured their non-dom- patients are young and physically active and, there- inant hand. For two patients the information of handed- fore, incapacitated in their hobbies, mostly sports. ness was missing. The mean time from injury to opera- This study reports the findings of lunotriquetral tion was 19 months (range : 1 to 120). lesions during arthroscopy and the clinical results obtained after dorsal stabilisation using extensor Clinical tests retinacular split. Clinical tests Preoperative lunotriquetral ballottement test results PATIENTS AND METHODS were available for 17 patients, of which 8 (47%) had a positive and 9 (53%) a negative result. Of the 19 patients Patient demographics and injury mechanisms with available information on the preoperative Watson test, 15 (79%) had a positive result and 4 (21%) had a The first author performed 28 lunotriquetral stabilisa- negative result. All those fifteen patients (58%), who tion operations on consecutive patients from 1998 to were tested using midcarpal provocation test, had a neg- 2003 using the technique described below. Of the ative test result ; 11 (42%) patients had not been tested 28 patients who had undergone stabilisation surgery for using this test.

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Arthroscopy Wrist arthroscopy was performed using five routine portals of which three had a radiocarpal location and two a midcarpal location. Finger traction was usually applied to the second and fourth fingers using 3-6 kgf, depend- ing on the weight of the patient. Counter-traction was T applied to the upper arm. L Arthroscopy was performed in operation room facili- ERS ties under general anaesthesia and using a tourniquet. If lunotriquetral instability was diagnosed in arthroscopy, ER the operation described below was performed in an open manner with the patient’s arm lying on the table and without counter-traction.

Lunotriquetral stabilisation

A dorsal operative approach was used. A lazy S- or Z- type skin incision was performed depending on the arthroscopic portals used. The extensor retinaculum was Fig. 1. — Lunotriquetral stabilisation using a dorsal operative exposed and depending on its width and strength, an 8- approach. Extensor retinaculum is exposed and depending 10 mm wide and radial-based strip was harvested distal- on its used width and strength, an 8-10 mm wide and radial- ly from the extensor retinaculum (fig 1). The dorsal sur- based split (ERS)is harvested distally from the extensor faces of both lunatum and triquetrum were exposed by retinaculum (ER). dividing the capsule obliquely. A fixing anchor (Mitek mini anchor, DePuy Mitek Inc., Norwood, MA, or Arthrex Small Bone FasTak titanium anchor, Arthrex Inc., Naples, FL) was inserted into both bones (fig 2). With the wrist in a neutral position in flexion-extension, ERS the strip was turned over the lunotriquetral joint and fixed to the anchor threads with proper tension. Using the same threads, the capsule was closed above the strip. The wound was closed and the pneumatic tourniquet was released. The operation was followed by a six-week immobili- sation, following which an active wrist mobilisation program was started, and gradually increased loading L T was permitted 8 weeks after the operation. Additional procedures were performed in eight patients : seven had a distal radioulnar joint stabilisation and one had an arthroscopic wafer osteotomy of the Fig. 2. — Lunotriquetral stabilisation using a dorsal operative ulnar head. approach : a screw anchor is inserted into both lunatum (L) and triquetrum (T) for fixation of the extensor retinaculum split (ERS). Assessment of results

The mean time from the operation to the follow-up visit referred to in the present study was 39 months ing of the parameters mentioned above. In addition, any (range : 14 to 84). Results were determined by assess- new injuries to the wrist during convalescence and the ment of pain, range of motion (ROM/flexion-extension, level of physical activity were recorded after the opera- percentage of normal), grip strength (compared with the tion (table I). All post-operative evaluations were done uninvolved wrist), patient satisfaction and overall scor- by the second author.

Acta Orthopædica Belgica, Vol. 73 - 4 - 2007 454 I. ANTTI-POIKA, J. HYRKÄS, L. M. VIRKKI, D. OGINO, Y. T. KONTTINEN

Table I. — The form used for the assessment of patient results at the follow-up visit

Assessment Grading Points Pain no pain 4 occasional mild pain, no interference with activity 3 pain with overuse or lifting ; not severe enough to decrease activity 2 pain with overuse or lifting ; severe enough to decrease activity 1 severe debilitating pain or rest pain 0

Range of motion 100% 4 (% of normal) 75% to 100% 3 50% to 75% 2 25% to 50% 1 0% to 25% 0

Grip strength 100% 4 (compared with the uninvolved wrist) 75% to 100% 3 50% to 75% 2 25% to 50% 1 0% to 25% 0

Patient satisfaction excellent 4 good 3 fair 2 poor 1 failure 0

Overall scoring excellent 15 to 16 good 11 to 14 fair 7 to 10 poor < 7 Assessment of any new injury to the no/yes (description) wrist during convalescence Level of activity after the operation as before the operation/altered (description)

RESULTS capitohamate in four patients (15%) and distal radio-ulnar joint in three patients (12%). Preoperative findings in arthroscopy Results at follow-up visit None of the patients had a normal lunotriquetral space. Seven (27%) had space only for the thin tip At the follow-up visit, seven patients (28%) had of the 2 mm probe (grade I), 18 (69%) had space no pain whatsoever. Nine (36%) had occasional for the 2 mm probe itself (grade II) and one (4%) mild pain which did not interfere with activity. had space for the scope itself (grade III). Coexistent Nine patients (36%) experienced pain with overuse arthroscopic findings were : other instability (n = or lifting. In six of these cases, the pain was not 15, 58%), chondral lesions (n = 12, 46%), triangu- severe enough to decrease activity, while in three lar fibrocartilage complex rupture/avulsion (n = 11, cases it was. No patient had severe debilitating pain 42%), synovitis (n = 14, 54%) and scapho-trapezio- or rest pain. trapezoid arthrosis (n = 1, 4%). The other instabili- The range of motion was 100% of the normal in ties involved scapholunate in nine patients (35%), ten patients (40%). In all of the rest, it was 75% to

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100%. The grip strength was 100% of the normal in the ratepayer be it the patient or an insurance com- 13 patients (52%), 75% to 100% in 11 patients pany, it means lower costs, shortened over-all (44%) and 50% to 75% in one patient (4%). recovery and shorter sick leaves as everything is Patient satisfaction was excellent in nine (36%), performed in one session. good in 12 (48%), fair in four (16%) and poor in Normally the whole procedure lasts between 1- none. Overall scoring was excellent in six (24%), 1.5 hours. The aim is to maintain as much move- good in 16 (64%), fair in three (12%) and poor in ment as possible in the wrist joint after surgery and none. The follow-up data of one patient were to to avoid long immobilisation periods. For these some points incomplete and the outcome for this reasons, and possibly due to lack of experience, LT- patient was poor so he was reoperated. arthrodesis with more or less unpredictable The level of activity after the operation was as results (5, 6) has not been so popular in our unit. before the operation in 23 patients (88%). Of these Instead, if combined traumatic scapholunar and patients, 16 had no problems with the wrist what- lunotriquetral instability is found in arthroscopy, soever, and seven had some symptoms, such as ten- e.g. four-corner arthrodesis has been usually per- derness during or after heavy loading, which how- formed with promising results (IAP and JH, unpub- ever did not affect the level of activity. The level of lished data) quite comparable to those reported by activity was somewhat altered in one patient (4%) ; others (10). this patient had to give up climbing as a free-time Although lunotriquetral instability is not an activity, but could continue dancing on a profes- unusual injury, scapholunar instability is a more sional level as well as teaching in physical educa- common one. In general physician’s practice, it is tion. The level of activity was significantly altered difficult to exactly characterise and localise the in two patients (8%) ; one patient, who had worked pain and other symptoms due to lunotriquetral joint as a sales clerk, had to get a new, less straining job instability. This causes delay both in diagnosis and and the other, mentioned above, had to undergo a proper operative treatment. Most patients in our new operation due to problems with the wrist. series were referred to Orto-Lääkärit Medical Center relatively late which caused a delay in the DISCUSSION treatment between one to 120 months (mean : 19 months) after the injury. Therefore, all cases LT-instability can be either dynamic or static in except one were chronic in nature. Especially nature. If the strongest palmar part of the LT-liga- among chronic cases the symptoms of the ulnar ment complex totally disrupts it may lead to side of the wrist vary and concomitant lesions (dis- advanced (static) instability with VISI (volar inter- tal radio-ulnar joint injuries, chondral lesions of the calated segmental instability) position of the luna- ulnar side of the wrist, triangular fibrocartilage tum (4, 8). In advanced LT-instability, radiography complex injuries or sequaelae of fractures) make may reveal more information in addition to clinical the diagnosis and treatment challenging. In seven examination. In this series, all radiographs and patients an additional distal radio-ulnar joint MRI were normal as far as LT-joint was concerned stabilisation was also performed. This did not seem and did not provide any additional value. to affect the final outcome as one had excellent, Our treatment protocol enables first confirma- four good and two fair overall results. tion or exclusion of the diagnosis of LT-instability Clinically, palpation and tenderness over the LT- in arthroscopy, which can then directly be contin- joint are considered reliable tests. In our series, ued by performing dorsal repair of LT-instability. however, Reagan’s ballottement test (7) was posi- Although swelling due to arthroscopy and portal tive only in 47% of the cases. The sensitivity of this openings, which penetrate through the extensor test was lower than the preoperative Watson retinaculum, cause relative inconvenience during test (11), which was positive in 79% in the present harvesting the strip, this caused no major difficulty study. Although the Watson test is considered more for open LT-reconstruction in the same session. For specific for scapholunar instability, we have

Acta Orthopædica Belgica, Vol. 73 - 4 - 2007 456 I. ANTTI-POIKA, J. HYRKÄS, L. M. VIRKKI, D. OGINO, Y. T. KONTTINEN noticed among our 450 clinically examined and the literature, but the numbers of reports on liga- subsequently arthroscopied patients that the speci- mentous repair in chronic LT-joint instability are ficity of the Watson test for scapholunar instability scarce. De Smet et al (1) reported 13 patients, who seems to be relatively low. had been operated using a somewhat similar dorsal Radiographs and the MRI did not disclose any capsular reinforcement with a retinacular flap with pathology in the LT-joint in the present patient five poor, five moderate and three excellent out- cases. Although high field MRI was used at that comes after a mean follow-up of 3.2 years. In time, intra-articular contrast medium was not used another study of 46 patients tenodesis of extensor but its use has since then become more common. carpi ulnaris tendon was used to repair LT-instabili- Our patients were evaluated postoperatively ty (9). In that series the results were excellent in 19, using a grading system originally reported by good in ten, satisfactory in eleven and poor in six. Glickel and Millender (3). It consists of four parts, In both series, complications led to reoperations in namely pain, range of motion (compared with the three cases. In our series only one reoperation was uninvolved wrist in per cent), grip strength (com- performed due to failure. The immobilisation time pared with the contralateral hand) and patient satis- used in the latter study (9) was 12 weeks, i.e. two faction, each of which is graded from 0 (failure) to times longer than in our study. 4 (excellent result). The overall score represents the In our opinion repair using extensor retinacular sum of these, with 16 being the maximum score. split is an easy and satisfactory procedure for the Only three patients had fair results. One of these treatment of chronic isolated lunotriquetral insta- patients had subsequently had a new injury which bility. It can also be safely performed in the same caused distal radio-ulnar joint instability, which session after arthroscopy without fear of complica- had been treated operatively. The remaining two tions. patients with only fair results had, in addition to LT stabilisation, also had a distal radio-ulnar joint sta- Acknowledgements bilisation performed in the same session. This study has been supported by the Victoria Foundation, The operative method used, i.e. dorsal “tighten- Finska Läkaresällskapet, the Juselius Foundation, the Invalid ing”, may in some cases interfere with the volar Foundation and EVO-grants. flexion of the wrist, which leads to only three out REFERENCES of four points in the range of motion without caus- ing any symptoms for the patient (60% of the cases 1. De Smet L, Janssens I, Van Ransbeeck H. Chronic had grade 3 ROM, with none having lower ROM lunotriquetral dissociation : dorsal capsular reinforcement grades). In the dominant hand the grip strength is with a retinaculum flap. Acta Orthop Belg 2003 ; 69 : 515- normally stronger compared with the non-domi- 517. 2. Garcia-Elias M, Geissler WB. Carpal instability. In : nant hand. In our series the injured hand was dom- Green DP, Hotchkiss RN, Pederson WC, Wolfe SW (eds). inant in half of the cases. Therefore, this compen- Green’s Operative Hand Surgery. Churchill Livingstone, sates the possible error due to the dominance of the Philadelphia 2005. affected hand. 3. Glickel SZ, Millender LH. Ligamentous reconstruction Patient satisfaction and the overall scores corre- for chronic intercarpal instability. J Hand Surg 1984 ; lated well in our 26 patients, with 21 patients 9-A : 514-527. 4. Horii E, Garcia-Elias M, An KN et al. A kinematic study (81%) having either excellent (n = 9) or good (n = of luno-triquetral dissociations. J Hand Surg 1991 ; 16-A : 12) subjective results, whereas the overall scores 355-362. were either excellent (n = 6) or good (n = 16) in 22 5. Kirschenbaum D, Coyle MP, Leddy JP. Chronic luno- (85%) of cases. triquetral instability : diagnosis and treatment. J Hand The operative treatment of lunotriquetral injuries Surg 1993 ; 18-A : 1107-1112. 6. Nelson DL, Manske PR, Pruitt DL et al. Lunotriquetral is not evidence-based and the gold standard for arthrodesis. J Hand Surg 1993 ; 18-A : 1113-1120. isolated LT injuries does not exist yet. Results of 7. Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral arthrodesis of the LT-joint have been validated in sprains. J Hand Surg 1984 ; 9-A : 502-514.

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8. Ritt MJ, Linscheid RL, Cooney WP 3rd et al. The lunotri- 10. Trumble T, Bour CJ, Smith RJ, Edwards GS. quetral joint : kinematic effects of sequential ligament Intercarpal arthrodesis for static and dynamic volar inter- sectioning, ligament repair, and arthrodesis. J Hand Surg calated segment instability. J Hand Surg 1988 ; 13-A : 1998 ; 23-A : 432-445. 384-390. 9. Shahane SA, Trail IA, Takwale VJ et al. Tenodesis of the 11. Watson HK, Ashmead D 4th, Makhlouf MV. extensor carpi ulnaris for chronic, post-traumatic lunotri- Examination on the scaphoid. J Hand Surg 1988 ; 13-A : quetral instability. J Bone Joint Surg 2005 ; 87-B : 1512- 657-660. 1515.

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